At the Crossroads: The Intersection of the Internet and Clinical Oncology

As is evident to anyone who has sought medical information on the Web in the past year, an enormous and rapidly expanding number of health-related sites provide unprecedented access to a vast spectrum of cancer information, from the clinical to the hyperbolic. The article by Pergament and colleagues examines the pressure that this information revolution is placing on the patient-physician relationship. The authors review the advantages and disadvantages of the Internet for both patients and oncologists, and suggest three actions physicians can take to manage the Internet’s impact on the interaction between patient and physician: (1) know what resources are on the Web, (2) use the web-based information that patients acquire, and (3) actively use the Internet themselves.

Article’s Strengths and Limitations

The most useful and important statement that this article makes is that ignoring the Internet or resisting its intrusion into the patient-physician relationship is a strategy that, while appealing to the overworked clinician, is doomed to failure. The authors also correctly point out that oncologists can establish enriched relationships with well-informed patients. The suggestion that such a patient population might comply better with treatment regimens is an intriguing one that merits study and quantitative analysis. (By the same token, the contradictory assertion that Net-savvy patients may be more insistent on trying alternative therapies that they discover on the Net also requires study and supporting data.)

In many other areas, however, the authors either do not provide sufficient and concrete information for clinicians to use or ignore relevant aspects of the Internet and its current and near-term impact on the practice of oncology. In particular, by considering patients and physicians as two distinct groups with respect to the benefits and problems associated with Internet use, the article omits elements common to all on-line medical information-seekers. This deficit leads to a circumscribed understanding of the ways in which oncologists and patients can maximize the benefits of the Internet in cancer care.

The authors’ discussion of the Web also limits itself to medical information and applications, but these resources do not exist in a vacuum. They are part of an extraordinarily dynamic Internet economy subject to market forces, regulatory issues, changing technology, and maturing demographics. These larger issues will certainly help shape the interaction of oncology and the Internet.

Finally, the questions of privacy and confidentiality concerning patient information that is stored, transmitted, and discussed over the Internet require further attention and discussion.

Shared Problems and Potential Solutions

The authors suggest that the explosion of health information–seekers on the Internet and the concomitant (and increasingly frequent) phenomenon of a patient arriving at clinic with web printouts in hand pose an inherent challenge to the authority of physicians as information sources. As the authors note, many patients view their new access to information as a source of empowerment and the key to being an active participant in their own health care. Thus, there is an opportunity for oncologists to work productively with the information-seeking patient, rather than fear “losing control” of information dissemination and patient-physician interactions.

Although the authors recognize this opportunity, they do not focus on the shared difficulties faced by oncologists and patients when sorting through web-based information and, thus, do not discuss potential solutions that could meet the needs of both. In their section, “Disadvantages of the Internet for Oncology Patients,” the authors describe the difficulty patients face in discerning the validity of information on the Web, and their inability to properly assimilate complex medical data from such sources as journals and research abstracts. In the next section, “Advantages of the Internet for Clinical Oncologists,” the authors cite “instantaneous access to information” as the primary advantage for clinicians responsible for assimilating new research into optimal patient care.

In fact, all individuals seeking health information on the Web experience both information flow and overflow. This is part of the fundamental equation underlying the Web: The act of publishing is immediate and global, and it is very nearly as easy to publish as it is to read what is published. Just as both patients and oncologists can benefit from expanded, facile access to information, patients and oncologists alike can be overwhelmed by the results, whether from lack of training or lack of time.

Moreover, the universe of information appropriate for a well-educated patient, a nonspecialist physician, and, on some occasions, an oncologist overlap and interconnect. Any solution that will enable the swift, efficient retrieval of relevant information presented in sufficient (and only sufficient) detail will have benefits for all of those seeking cancer information.

Commercial Information-Providers

The need for credible, manageable medical Internet resources has not gone unnoticed by commercial information- providers. Medical information is one of the most competitive, fastest-growing segments of the information economy‚ and as part of that economy, is subject to the trends shaping the Web at large. The Web is becoming more corporate and less counterculture, and information anarchy is gradually being overlaid by “portal” sites that seek to filter and package subsets of information for relevant audiences. These sites draw enormous traffic from information-seekers desperate for order and a better return on their on-line time.

This type of “portal” site is springing up in the lucrative medical field. These largely commercial enterprises are primarily designed to aggregate medical information into packages tailored to sophisticated consumers and busy clinicians, from inter-active symptom databases to “executive” research summaries. Market research and the individual needs of a cancer patient may not always intersect, however, and it is in this context that oncologists can play a vital role as interpreters and editors of the information retrieved by patients on-line.[1]

Evaluating Web Sites

As the authors recommend, in order to play this role oncologists need to assemble a working knowledge of useful on-line resources for themselves and their patients. However, the suggestions offered in the section, “Become Familiar With Cancer Information on the Internet,” could have benefited from greater technical precision and should have been supplemented with several practical guidelines.

As an example, the authors’ statement that “X [as in com/edu/gov] indicates the type of organization that has created the site” in Web addresses is misleading; such a designation merely denotes some affiliation with the organization owning the primary domain name, not necessarily the site’s creator or content provider. This can be a crucial distinction, since many organizations rent space on commercial (“.com”) servers for their sites, and universities (“.edu”) often offer server space to current and former students, as well as faculty and departments.

In contrast, a clearly visible, sufficiently detailed statement of who is responsible for the content on the site, along with presentation of editorial policies, linking policies, and an obvious way to contact the site management, are commonly accepted guidelines for evaluating the legitimacy of a web site. As the authors mention, criteria used to judge the quality of printed medical information also apply on-line. A number of resources exist in print and on-line format that present this basic set of evaluation guidelines. These can be used by oncologists and provided to patients as part of the discussion of web-based information.[2-4]

Confidentiality and Privacy Issues

The article touches on the use of electronic mail (e-mail) in patient-physician correspondence, and reviews some of the legal and regulatory questions that this kind of communication engenders. Equally troubling are the implications for patient confidentiality and privacy in the increasingly wired medical world. As with so many other challenges, this subject is not limited to the health care environment, but is of paramount interest to many sectors of the Internet economy, such as the financial world. As with other areas cited in this review, the lessons learned in the business community can be fruitfully applied to the world of cancer information.

Health care providers need to make the commitment to support technical solutions, policies, and working guidelines that help safeguard the confidentiality and privacy of both the patient and the physician. If, as the authors suggest, the Internet is already inextricably intertwined with the delivery of care in this country, these issues should be of primary concern to patients and oncologists alike as they adjust to the presence of the Internet as a “third party in the doctor-patient relationship.”

References:

1. Seybold N: The role of the Internet in clinical oncology J Oncol Index Rev II 2:3-5, 1998.

2. Ambre J, Guard J, Perveiler FM, et al: Mitretek’s White Paper: Criteria for Assessing the Quality of Health Information on the Internet. Available at: http://www.mitretek.org/hiti/showcase.

3. See Virginia Polytechnic Institute and State University’s Bibliography on Evaluating Internet Resources. Available at: http://refserver.lib.vt.edu/libinst/critTHINK.HTM.

4. Kim P, Eng, TR, Deering MJ, et al: Published criteria for evaluating health related web sites: A review. Br Med J 318(6):647-649, 1999. Also available at: http://www.bmj.org.